枕下乙状窦后入路骨瓣开颅的技巧研究

目的探讨枕下乙状窦后入路骨瓣开颅的手术方法及技巧。方法对采用枕下乙状窦后入路骨瓣开颅手术的22例桥小脑角区病变资料进行回顾性分析。结果骨瓣开颅术均顺利完成，无一例损伤乙状窦和横窦，均获得满意的术野显露。骨瓣形成平均用时55min，术后无一例发生切121脑脊液漏和颅内感染。结论枕下乙状窦后入路骨瓣开颅术安全、可行，骨瓣复位后保持了原有的解剖结构。术中关键点是根据颅骨表面解剖标志定位，以良好地显露及避免损伤乙状窦和横窦。     

枕下乙状窦后入路骨瓣开颅的临床应用

目的 探讨枕下乙状窦后入路手术中改咬骨窗为骨瓣成形开颅并复位的应用。方法 回顾性总结我院自2003年6月至2006年12月26例枕下乙状窦后入路骨瓣开颅患者临床资料。具体操作方法：取乙状窦后入路，在后颅窝钻3个孔，铣刀锯下骨瓣，术毕严密缝合硬脑膜，骨瓣复位，用蛇牌颅骨锁2枚固定，不放置外引流。结果 骨瓣开颅顺利，骨瓣成形过程中出血量少，未发生横窦和乙状窦损伤，均获得满意的手术显露，骨瓣切除平均用时36min。脑组织保护好，术后无脑脊液漏、皮下积液、皮下血肿和颅内感染，未见手术部位硬膜外和硬膜下血肿发生，枕大神经解剖保存率达80％。结论 在显微神经外科基础上，枕下乙状窦后入路骨瓣成形开颅和复位是安全、快捷、可行的方法．值得推广应用。     

后颅窝骨瓣开颅、深部肌群分层缝合技术在枕下乙状窦后入路手术中的应用

目的 探讨枕下乙状窦后人路骨瓣开颅和复位,后颅窝深部肌群分层切开、缝合术的手术方法及临床应用. 方法上海市第十人民医院神经外科自2003年5月至2005年5月应用枕下乙状窦后入路骨瓣开颅、深部肌群分层切开缝合术治疗40例桥脑小脑角区肿瘤患者,对其临床资料进行同顾性分析.结果 骨瓣开颅均顺利完成,手术视野良好,平均用时40～70min;2例患者术后出现皮下积液,无脑脊液漏发生,多数患者数后第6天头部即可自由活动.结论经枕下乙状窦后入路骨瓣开颅、深部肌群分层缝合技术安全、快捷,可降低术后脑脊液漏、假性脑膨出的发生,并可使头部早期恢复自由活动.     

枕下乙状窦后入路骨瓣成形在微血管减压术的应用

目的探讨枕下乙状窦后入路单骨孔骨瓣成形在微血管减压术(MVD)的应用。方法回顾性分析54例MVD病例资料,其中34例使用单骨孔骨瓣成形开颅,20例使用枕骨切除开颅。总结骨瓣成形开颅的技术要点,并比较两组病人术后并发症发生率。结果 34例骨瓣成形开颅的病人,手术操作顺利,术区显露满意,无硬膜、静脉窦损伤,术后骨瓣复位良好,未见脑脊液漏、枕部皮下积液等并发症。20例使用枕骨切除开颅病人,3例(15%)发生枕部皮下积液,1例发生(5%)脑脊液漏。结论经枕下乙状窦后入路骨瓣成形开颅操作安全,恢复颅骨结构的完整性,可有效减少术后并发症发生。     

枕下骨瓣开颅术治疗后颅窝病变

目的 应用枕下骨瓣开颅术治疗后颅窝病变，与传统的枕下骨窗开颅术比较探讨其优越性。方法92例后颅窝病变，枕下骨瓣开颅48例，骨窗开颅44例。分别采用乙状窦后、后正中和旁正中三种手术入路。结果 骨瓣开颅组术后CT显示骨瓣复位良好，术后无脑脊液漏，皮下积液6例，颅内感染5例。骨窗开颅组术后脑脊液漏3例，皮下积液9例，颅内感染4例。两组比较无统计学意义。骨窗开颅组有不同程度的创口凹陷。结论 虽然骨瓣开颅组术后无脑脊液漏，但是尚不能说明骨瓣复位能减少脑脊液漏的发生，是否骨瓣复位与术后皮下积液和颅内感染亦无明显关系。骨瓣复位保持了解剖层次的完整性，避免了术后颅骨缺损对患者的不良心理影响。     

瓣状肌肉切口、骨瓣开颅在枕下乙状窦后入路手术中应用的体会

目的探讨枕下乙状窦后入路手术的方法及临床应用。方法回顾分析经枕下乙状窦后入路瓣状肌肉切口和骨瓣开颅手术的32例桥小脑角区病变病人的临床资料。结果全部患者均获得满意术野显露,术野显露平均用时45min;无脑脊液漏和皮下积液发生,术后1例发生颅内感染,经抗炎治疗后恢复。全部患者半年后随访,切口愈合良好,局部肌肉无明显萎缩。结论枕下乙状窦后入路瓣状肌肉切口和骨瓣开颅可有效降低手术后脑脊液漏、皮下积液和颅内感染的并发症,是安全可行的手术方法。     

改良乙状窦前入路切除岩斜区肿瘤

目的介绍一种新的、改良的乙状窦前入路的开颅方法。方法对124例岩斜区肿瘤,通过颞枕小脑幕上下双骨瓣开颅、改良乙状窦前入路手术方式,探讨传统乙状窦前入路和改良乙状窦前入路的优缺点。结果124例改良乙状窦前入路,手术中无静脉窦破裂出血的发生,术后无颅骨缺损、局部积液的发生。手术操作安全、简便、易于掌握。结论改良乙状窦前入路在传统入路基础上,通过对开颅骨瓣的改良,避免了手术中静脉窦损伤、手术后颅骨达到完全解剖复位,不仅使局部美观,还有效地降低了术后并发症的发生。     

经枕下乙状窦后锁孔入路治疗听神经瘤的临床体会

目的 总结经枕下乙状窦后锁孔入路切除听神经瘤的手术经验. 方法 采用经枕下乙状窦后锁孔入路对38例听神经瘤进行切除手术.距乙状窦后缘内侧1.5 cm做一小直切口,形成直径2.5～3.0 cm大小骨窗,术毕骨瓣复位固定. 结果本组听神经瘤全切33例,次全切5例;35例面神经解剖保留,2例听力保留;无死亡病例,脑脊液漏1例,术中无一例输血,无皮下积液.结论 经枕下乙状窦后锁孔入路可提供足够的手术空间进行听神经瘤切除,明显减少了医源性损伤,切口愈合好,具备微创性、安全性和有效性.     

经枕下乙状窦后锁孔入路治疗听神经瘤的临床体会

目的 总结经枕下乙状窦后锁孔入路切除听神经瘤的手术经验. 方法 采用经枕下乙状窦后锁孔入路对38例听神经瘤进行切除手术.距乙状窦后缘内侧1.5 cm做一小直切口,形成直径2.5～3.0 cm大小骨窗,术毕骨瓣复位固定. 结果本组听神经瘤全切33例,次全切5例;35例面神经解剖保留,2例听力保留;无死亡病例,脑脊液漏1例,术中无一例输血,无皮下积液.结论 经枕下乙状窦后锁孔入路可提供足够的手术空间进行听神经瘤切除,明显减少了医源性损伤,切口愈合好,具备微创性、安全性和有效性.     

经枕下乙状窦后锁孔入路治疗听神经瘤的临床体会

目的 总结经枕下乙状窦后锁孔入路切除听神经瘤的手术经验. 方法 采用经枕下乙状窦后锁孔入路对38例听神经瘤进行切除手术.距乙状窦后缘内侧1.5 cm做一小直切口,形成直径2.5～3.0 cm大小骨窗,术毕骨瓣复位固定. 结果本组听神经瘤全切33例,次全切5例;35例面神经解剖保留,2例听力保留;无死亡病例,脑脊液漏1例,术中无一例输血,无皮下积液.结论 经枕下乙状窦后锁孔入路可提供足够的手术空间进行听神经瘤切除,明显减少了医源性损伤,切口愈合好,具备微创性、安全性和有效性.     

儿童后颅窝肿瘤手术入路及骨瓣复位

目的：根据后颅窝肿瘤不同部位选择最佳手术入路。后颅窝开颅术改咬骨窗为开骨瓣。方法：蚓部肿瘤选择后颅窝正中入路。小脑半球肿瘤行正中钩形切口，肿瘤偏外选择外侧钩形切口。上蚓部肿瘤选择Ｐｏｐｐｅｎ入路。三种骨瓣：正中骨瓣、单侧骨瓣、单侧跨中线骨瓣。术毕骨瓣复位。结果：实施３８例儿童后颅窝肿瘤全切除术，髓母细胞瘤２３例，星形细胞瘤１０例，室管膜瘤３例，血管母细胞瘤１例，脑脓肿１例。无皮下积液发生，３例术后１０天内发烧。结论：后颅窝开骨瓣术、硬膜缝合、骨瓣复位符合解剖复位原则，术后并发症少，避免了因颅骨缺损造成的对儿童心理发育的不良影响     

Surgical treatment of dumbbell-shaped jugular foramen schwannomas via two-piece lateral suboccipital approach: Report of 26 patients

BackgroundDumbbell-shaped jugular foramen schwannomas (JFS) are rare but challenging for the treatment. Surgical resection is believed to be the optimal therapy; however, postoperative dysfunction of the lower cranial nerves (CNs), tumor residual, cerebrospinal fluid (CSF) leakage, and subcutaneous hydrops are common. The current study's objectives were to describe the optimal surgical strategies for the total removal of dumbbell-shaped JFS, the functional preservation of lower CNs, and the prevention of postoperative CSF leakage.Methods26 consecutive patients with dumbbell-shaped JFS were surgically treated between January 2014 and June 2019. All patients were operated on via two-piece lateral suboccipital approach, vascularized muscle flap was used for the repair of the dural defect after an operation. The clinical information and radiological data of these patients were retrospectively reviewed, and the optimal surgical strategies were further evaluated and discussed.ResultsThe tumor was completely removed in all 26 patients, one patient developed new CN Ⅶ paralysis, and 2 developed new CN IX and Ⅹ paralysis after an operation, all patients were significantly relieved during follow up. None of them developed subcutaneous hydrops and postoperative CSF leakage. No tumor recurrence was observed during a mean follow up of 38.8 (16–69) months.ConclusionsDumbbell-shaped JFS could be safely and completely removed via the two-piece lateral suboccipital approach. Postoperative CSF leakage could be effectively prevented by careful repair of the dural defect in the jugular foramen (JF) and filling the mastoid cavity with a vascularized muscular flap.     

New method of bone reconstruction designed for skull base surgery.

The direct endonasal or transoral transclival approaches to the skull base permit effective, minimally invasive surgery along the clivus. Developing long-term, effective techniques to prevent cerebrospinal fluid (CSF) leaks and their consequences (infection and delayed healing) remains a major challenge. In this study we describe a method of bone reconstruction newly developed by us, which uses a custom designed silicone plug for bone replacement after minimally invasive skull base surgery with a low incidence of postoperative CSF leaks. German Landrace pigs were used to test the efficiency of the new technique. Twelve craniotomies were performed in six pigs using a subtemporal approach and subsequently the dura was opened. After these preparations the craniotomy defects were occluded with a silicone ball, which had a near spherical shape. The ball elastically adapts to the bone defect. Each pig also received an intracranial pressure (ICP) catheter and a subdural catheter for later fluorescein injection. Then we increased ICP by infusion of artificial CSF and detected fluorescein leaks from the craniotomy using ultraviolet illumination and a photomacroscope equipped with appropriate filters and a charge-coupled device camera. In all pigs we increased ICP to 75-80 mmHg by infusing 25-30 mL saline containing 0.05% sodium fluorescein. For the first four craniotomies infusions were interrupted after CSF leaks occurred due to technical failures, which were subsequently rectified. The following eight craniotomies were watertight without CSF leakage. This novel medical device allows a leak-proof closure of bone defects after minimally invasive craniotomies; no additional surgery or other therapies were necessary. The application of the silicone plug, which is made of a cost-effective and biocompatible material, is easy and fast, making use of a specially developed toolkit.     

腰大池引流治疗术后颅内感染及脑脊液漏

目的探讨持续腰大池引流治疗术后颅内感染及脑脊液漏的疗效。方法回顾性分析2004年2月至2007年10月经持续腰大池脑脊液引流治疗的39例术后颅内感染及脑脊液漏患者的临床资料。这39例患者中，单纯脑脊液切口漏11例，脑脊液鼻漏9例，单纯颅内感染8例，脑脊液切口漏合并颅内感染11例。结果27例行腰大池持续外引流，12例经腰大池外引流并辅以鞘内注入敏感抗生素治疗，均取得满意疗效，无加重及脑疝等严重并发症发生，所有患者均痊愈出院。结论应用持续腰大池引流脑脊液加鞘内注药，配合全身应用敏感抗生素是治疗术后脑脊液漏及颅内感染一种安全、有效的方法。     

颅后窝骨瓣成形术在显微神经外科手术中的应用

目的探讨颅后窝骨瓣成形术的作用与意义.方法回顾性分析21例颅后窝骨瓣开颅术,其中听神经瘤8例,小脑星形细胞瘤5例,脑于胶质瘤4例,小脑出血2例,延髓内神经鞘瘤、小脑蚓部淋巴瘤各1例.采用双侧或单侧开瓣,术毕严密缝合硬脑膜,骨瓣回纳固定,不放置外引流.结果肿瘤全切除或近全切除17例,仅脑干胶质瘤行部分或大部分切除.随访12～36个月,平均21.5个月.术后无持续低热、颈枕部疼痛、脑脊液漏等并发症,脑保护好,外观满意.结论在显微神经外科的基础上,采用颅后窝骨瓣成形术可提供良好的脑保护.     

经鼻蝶入路垂体手术中及手术后脑脊液漏的防治

目的研究经鼻蝶入路垂体手术中及手术后脑脊液漏的发生率、影响因素,并探讨术中及术后脑脊液漏的防治方法。方法回顾性分析武汉大学人民医院神经外科2006年5月至2011年12月行经鼻蝶入路垂体手术276例患者（其中垂体腺瘤270例,垂体脓肿3例,粘液囊肿2例,垂体转移瘤1例）的临床资料,并对术中、术后脑脊液漏的防治进行探讨。结果108例（39．1％）术中发生脑脊液漏,14例（5．1％）术后出现脑脊液漏（1例合并脑膜炎）。14例术后脑脊液漏患者中,8例平卧5～7d后脑脊液漏消失;6例经蝶窦再探查,重新封闭后3例治愈,1例行腰椎穿刺置管脑脊液引流5d后治愈,2例引流1周症状无改善,经内镜修补漏口后脑脊液漏停止。未发现患者年龄、性别、肿瘤生长方式、肿瘤类型、手术放疗史与术后脑脊液漏之间有相关性。结论术者经验是减少术中脑脊液漏的重要因素,积极重建封闭鞍底是预防术后脑脊液漏的关键,及时重新蝶窦探查,封闭鞍底,选择性腰椎置管引流,必要时经内镜等措施修补漏口,可有效治疗术后脑脊液漏。     

小骨窗开颅显微手术治疗高血压基底节区脑出血临床分析

目的探讨小骨窗开颅显微手术治疗高血压基底节区脑出血的临床疗效。方法收集84例高血压基底节区脑出血患者的临床资料,按手术方式不同分为小骨窗开颅显微手术组(观察组)和传统大骨瓣开颅手术组(对照组)各42例,2组术后均给予规范化综合治疗,比较2组术后并发症及术后3个月ADL评分、再出血率及平均住院时间等。结果观察组和对照组术后并发症的发生率分别为11.90%和30.95%,2组比较差异有统计学意义(P<0.05);观察组术后ADL评分明显显著优于对照组(P<0.05);2组术后血肿复发率、病死率及血肿清除率比较差异均无统计学意义(P>0.05)。结论与传统大骨瓣开颅手术比较,小骨窗显微手术治疗高血压基底节区脑出血具有创伤小、术后神经功能恢复好、并发症少及住院时间短等优点,值得临床推广应用。     

En bloc mastoidectomy to avoid postoperative retroauricular deformity in the transpetrosal approach

The authors describe a surgical technique to avoid postoperative retroauricular deformity following the transpetrosal approach. After removing a one-piece temporal and suboccipital bone flap, the mastoid process is cut obliquely by using a sagittal saw towards an imaginary line drawn from the point on the petrous ridge just lateral to the arcuate eminence to the burr hole opened medial to the occipital groove. This technique allows en bloc removal of the mastoid process without resulting bone defects. Three patients who were treated with this technique and followed up for more than 1 year showed good cosmetic results with no complications including cerebrospinal fluid leakage. We believe this en bloc mastoidectomy offers a definite advantage in regard to avoid postoperative retroauricular deformity.